Provider Demographics
NPI:1528547494
Name:D'AGOSTINO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:D'AGOSTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:D'AGOSTINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2613 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-2133
Mailing Address - Country:US
Mailing Address - Phone:626-554-0408
Mailing Address - Fax:
Practice Address - Street 1:2613 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2133
Practice Address - Country:US
Practice Address - Phone:626-554-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2023-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043536B103TC0700X, 103TH0100X
IN20043536A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical